On Friday, the Trump administration introduced its new Promoting Human Flourishing in Foreign Assistance (PHFFA) policy, which expands the Global Gag Rule to its most extreme version to date and imposes alarming new conditions, in an attempt to reshape US foreign assistance along ideological lines.
The policy intensifies its prohibition on safe abortion care and adds extensive restrictions on other categories of health and rights, including gender-affirming and diversity, equity, and inclusion (DEI) frameworks. These moves directly contradict established medical consensus and evidence-based standards for delivering effective health care and humanitarian assistance.
Doctors Without Borders/Médecins Sans Frontières (MSF) is deeply concerned that this policy will cause serious harm to communities in crisis and cut off the most marginalized people from essential and lifesaving health care.
"These changes to the Global Gag Rule raise serious concerns for patient well-being, safety, and continuity of care," said Tirana Hassan, MSF USA CEO. "MSF has witnessed firsthand the irreparable damage caused by previous versions of the Global Gag Rule. Expanding it and introducing a series of new draconian restrictions will only deepen that harm, eroding global health standards, and denying people the care they urgently need."
The PHFFA escalates a pattern established across both Trump administrations: the systematic subordination of scientific evidence and patient needs to ideological and political objectives. Versions of the Global Gag Rule have been introduced by Republican administrations since 1984, and extensive research has repeatedly documented that the policy disrupts health services and causes cascading adverse health outcomes in low- and middle-income countries, with the chilling impact enduring even when the policy has been rescinded.
In 2017, the administration expanded the Global Gag Rule, also known as the Mexico City Policy, to include all US global health assistance, prohibiting foreign NGOs from providing, referring, counseling, or advocating for abortion — even with their own non-US funds, and even in countries where abortion is legal.
The PHFFA goes much further. For the first time, it applies Global Gag Rule restrictions to all non-military foreign assistance, including humanitarian aid for communities facing acute crises. The policy also dramatically expands who must comply: foreign and US-based NGOs, international organizations, parastatals, and foreign governments must now accept these restrictions and flow them down to every organization they fund.
Beyond expanding abortion restrictions, the PHFFA applies extensive restrictions to activities it claims promote so-called "gender ideology" and "discriminatory equity ideology." The policy defines these terms so broadly that it is likely to result in barring or limiting access to essential health services for LGBTQIA+ individuals, women and girls, racial and ethnic minorities, and other marginalized groups.
These restrictions entrench an approach deployed by the administration last year: using intentionally vague, mischaracterized, and overbroad notions of gender and equity to justify the elimination of funding for vital programming including HIV prevention, gender-affirming care, contraception, community health programs, maternal and child health services, and care for survivors of sexual violence. The policy now attempts to make permanent and enforceable what was carried out through ad hoc program cancellations last year. Organizations worldwide will be put into the impossible position of choosing between accepting ideological restrictions to secure increasingly scare funding and providing evidence-based care that meets international medical standards.
To enforce these restrictions, the PHFFA establishes an expansive, alarming, and extraordinarily paternalistic compliance regime. According to the policy, US government representatives may conduct unannounced site visits to inspect organizations' activities. MSF fears this approach could compromise patient privacy, confidentiality, and safety, particularly for survivors of sexual violence and members of marginalized communities seeking care.
Since navigating requirements under this expanded policy is likely to be both difficult and confusing, MSF expects its impact to be magnified by over-compliance and chilling effects on lawful services, reducing access to a wide range of health programming including maternal and child health, contraception, cervical cancer screening, HIV prevention and testing, and post-abortion care.
By the US government’s own estimate, implementing this new policy will collectively cost service providers at least $340 million annually in administrative burden — dollars spent not on health, but on ensuring alignment and compliance with the US government’s ideological standards.
“Such an intense level of administrative burden puts added stress on providers and health systems,” said Rachel Milkovich, MSF USA senior specialist for global health advocacy and policy. “In humanitarian emergencies, we expect to see these stressors compound. This policy was clearly not designed with the realities of fragile and conflict-affected health systems in mind. For decades, the Global Gag Rule has had massive chilling effects on lawful, evidence-based health services. This new policy is even more pervasive, impacting more funding streams, more partners, and more health programs than ever before."
Although MSF does not accept US government funding and will not be required to comply with the policy, the new restrictions risk disrupting critical partnerships, supply chains, and community health programs on which MSF's teams and patients rely.
"We expect that this reckless policy will weaken entire health systems, fragment referral networks, censor medical professionals, and create dangerous barriers both accessing and providing lifesaving care," said Hassan. "The people who will pay the price are precisely those most in need. Medical care should be based on patient needs and scientific evidence, not on whether treatment aligns with a donor government's political ideology."
